POLICY BRIEF ON ICT APPLICATIONS

IN THE KNOWLEDGE ECONOMY

ISSUE NO. 7 DECEMBER 2009

Improving health care in rural areas:

Information and communications technology solutions
for least developed countries
The Millennium Development Goals (MDGs) set
targets to address the most critical areas affecting
development by 2015. In the area of human health,
such targets include the reduction of the mortality rate
of children under five years old by two thirds (MDG 4),
the reduction of the maternal mortality ratio by three
quarters (MDG 5) and the halting and reversing of the
spread of HIV/AIDS, malaria and other major
diseases (MDG 6).
The Asian and Pacific region suffers 41% of the
world’s deaths of children under five and 43% of the
world’s maternal deaths. It leads by far in the
prevalence of tuberculosis, with more than 8 million
people affected, as illustrated in figure 1. The rate of
infant mortality is almost twice that of Latin America
and the Caribbean.1 Between 2001 and 2007, the
number of people living with HIV nearly tripled in the
Pacific and increased by one and a half times in North
and Central Asia.1 Recent threats, such as the H1N1
2009 flu pandemic, further affect the health of
children, pregnant women and the population at large.
Moreover, health-care facilities and personnel are
more concentrated in urban areas than in low
population density areas. In the region, child under-
five mortality rates are typically far higher in rural than
urban areas, often by over 50 per cent. 2
It is recognized among health specialists that
achieving the health-related MDGs requires
strengthening health systems, particularly in the
following areas:
(a) Expanding the primary health-care workforce
and enriching the skill levels; 3
(b) Upgrading and broadening medical
infrastructure and logistics; 3
(c) Providing affordable access to drugs and
medical supplies; 4
(d) Improving health decision-making and early
warning by enhancing data collection and
analysis of disease trends. 3
This brief summarizes cost-effective information and
communication technology (ICT) applications to
support improvements in these four areas in least
developed, landlocked and small island countries in
the Asia-Pacific region, and recommends policy
options to better benefit from such applications.

Figure 1. Indicators related to the MDGs 4, 5 and 6

Source: Tuberculosis: The Millennium Development Goals: Progress in Asia and The Pacific 2007.

United Nations Economic and Social Commission for Asia and the Pacific
Expanding the health-care
workforce and enriching the skill
levels in rural areas
The Asia-Pacific region is underserved by health-care
workers (20 per 10,000 persons in 2007). This is a
consequence of factors such as emigration, low levels
of investment in human resources and poor working
conditions. To address this problem, ICT can be
applied in the following areas.
ICT Training for health workers in rural areas
ICT can be used to provide cost-effective and efficient
training and to develop skills among local health
workers, resulting in not only better skilled health
workers but also an increase in the number of
trainers. With distance learning and computer-based
training, trainees can study independently using
standardized materials on CD-ROM, the Internet, and
using video-conferencing facilities. This mode of
learning may be used as a substitute or complement
to training activities which do not require or need
fewer hands-on demonstrations by an instructor.
Training materials which use multi-media technology
can illustrate medical cases and transfer skills and
knowledge in interactive ways, which are not always
possible in traditional classrooms. Computer-based
training has proven to be cost-effective and of
equivalent quality to classroom training for first-level
health providers in least developed countries. A study
comparing the results of a computer-based training
and a standard training for the Integrated
Management Childhood Illness (IMCI) found that
there was no difference in the level of knowledge and
skills acquired between the two methods, and ICT-
based training may decrease the time and number of
facilitators, resulting in cost savings of almost 30 per
cent. 5
ICT for skill building in health services
Providing health workers with tools and information
that complement their skills is another way to
strengthen health services in rural areas. Free basic
health reference materials are increasingly available
on the Internet, such as http://healthy-india.org/ in
India and the self-help guide provided at
www.nhsdirect.nhs.uk, which can be useful to health
workers as well as the population at large. 6
These reference materials and diagnostic tools can be
accessed on affordable portable computers and even
from some mobile phone handsets. For example, a
University of Melbourne project installs reference
materials and calculators for determining drug dosage
on mobile telephones used by health workers in rural
areas of developing countries. 7 Similar portable tools
could also be directly used by people who may not
have access to a health worker.
2
ICT for Tele-consulting
Telemedicine refers to the remote diagnosis and
consultation of patients by doctors without being in
physical contact. The parties may be separated by
long distances and be located in under-served and
rural areas. It includes tele-consulting, which in its
simplest form involves the exchange of health
information by voice between a doctor and a rural
health worker assisting a patient. Tele-consulting “call
centres” can be established to provide rural health
workers, who may have limited medical skills, with a
dedicated phone line to consult with more specialized
doctors.
Limited scope call centres have been successful in
many developing countries in providing access to
medical advice through free or low-cost telephone
numbers to people facing social pressure not to solicit
advice for certain illnesses, such as sexually
transmitted diseases, HIV/AIDS and mental health
problems.
Telemedicine also includes tele-radiology, tele-
pathology, and the provision of surgery advice and
instructions, all of which involve the transmission of
images among different sites.8 With the increasing
availability of connectivity in rural areas and the
reduced prices of communication devices, some of
these applications are more accessible to least
developed countries. Examples include sending text
message reminders for taking medication and
vaccination follow-ups. In Thailand, tuberculosis
patients receive daily text message reminders,
resulting in over 90 per cent adherence.7
Public awareness
One precondition for halting the spread of HIV/AIDS,
malaria and other diseases, such as H1N1 flu, is for
people to understand how these illnesses are
transmitted. Mass media health awareness
campaigns have proven to be effective, though in
some cases they may be expensive. In such cases,
targeted campaigns through local radio and mobile
phones could be an alternative. Mobile phones
provide a high penetration level and an additional
level of privacy not offered by other mass media. For
example, in some countries, governments are sending
text messages to mobile phone users to promote
HIV/AIDS testing and awareness hotlines; in one such
case, the campaign resulted in a considerable
increase in calls to the hotline.7 However, legislation is
required in order to ensure that such information
comes from credible sources.
Upgrading and broadening
medical infrastructure and
logistics
Most of the least developed countries do not have
enough resources to establish new primary health-
care facilities in rural areas; the selection of their
locations is therefore critical. geographic information
systems (GIS), which integrate and analyse relevant
geographical and demographic data, have been
helpful in identifying locations which are safe from
disasters and easily reachable by a large portion of
the population, and which may be particularly
disease-prone. For example, WHO distributes the
HealthMapper system, which facilitates data
collection, updating and visualization of health
information in the form of maps, tables and charts.
ICT can support building the necessary health
infrastructure in developing countries in several ways.
Examples include public-private partnerships for the
construction and operation of health-care facilities.
Additionally, ICT can facilitate the sharing of
information, such as clinic construction blueprints,
ready-made public health awareness materials, free
software in local languages for managing health-care
centres and electronic processing of permits and
other paperwork.
Providing affordable access to
drugs and medical supplies
Market efficiency: In most developing countries,
there have always been considerable gaps between
the demand for and supply of drugs and medical
equipment/tools. Furthermore, their prices depend on
various factors, including import tariffs and the
availability of local generic alternatives to brand name
drugs. In countries where the government procures
drugs or medical supplies directly with public funds,
decision makers at the national and provincial levels
look into pooling purchases into higher volume orders
to obtain better prices. When rural health-care centres
are provided with sufficient means of communication,
they can inform provincial health centres about their
inventory of medicines. Such information can be
aggregated in inventory systems and used to allocate
medicines in response to actual demand in each
province.
In situations where the markets have multiple buyers
and sellers of drugs and medical supplies, information
on supply and demand makes prices more
competitive. Governments worldwide have been
promoting the establishment of electronic
marketplaces which provide business directory listings
and electronic catalogues and facilitate transactions
between buyers and sellers.
Scientific information for producing affordable
drugs: An alternative to procuring drugs is producing
them. Some developing countries have developed
pharmaceutical industries capable of manufacturing
generic drugs. To foster health research, individuals
and companies need access to academic and field
research, some of which is readily available online,
3
though often at a high price. The Governments of
least developed countries may seek partners to gain
access to these resources. For example, the Health
InterNetwork Access to Research Initiative (HINARI),
a public-private partnership set-up by WHO, provides
LDCs free access to expensive knowledge bases
containing biomedical and health literature materials
(www.who.int/hinari/en).
Early warning and surveillance
systems for health care
Health early warning systems are surveillance
systems that collect information and apply statistical
methods to detect changes in general health trends
and epidemic-prone diseases. Such systems depend
on data being collected, analysed, interpreted and
made available to decision makers and the
community.
Data collection using multiple platforms: Having
knowledge about the health situation of people
dispersed over large rural areas has long been a
challenge, but thanks to the reduced cost of hand-
held electronic devices, ambulatory health-care
workers can report their findings easily and rapidly
back to headquarters. Data can be aggregated at
provincial or national databases, resulting in better
individual patient records, avoidance of paperwork
backlogs and the availability of up-to-the-minute
health reports and maps. For example, EpiSurveyor, a
software application promoted by the United Nations
Foundation and the Vodafone Foundation, enables
surveys to be created easily using mobile phones. 7
Fieldwork data collection is slow and expensive.
Space agencies are working on developing models
using data obtained from satellites which measure
conditions such as temperature, rain precipitation and
other factors to infer the probability of the spread of
diseases such as malaria, sleeping sickness, dengue
fever, rift valley fever and chikungunya.9 Remote
sensing technology may be used to analyse bird
migration routes in order to identify areas where
outbreaks of diseases, such as avian influenza, might
occur.
Analysis and decision making: Health policy- and
decision-makers need tools to assist them in their
work. Such tools include spatial information systems
designed to integrate and analyse historical and real-
time data and to display it in user-friendly ways. Such
systems can combine multiple layers of information
obtained on the ground and from satellites. This
information can be linked to statistical databases, for
example, those with figures on population density,
resulting in maps on which disease-prone areas can
be identified. Furthermore, such information could
also be used to establish spread models of certain
infectious diseases, to identify areas requiring urgent
assistance and to compare the solutions for more
effective control and prevention of their spread.
Challenges and recommendations
for improving health care in rural
areas using ICT
It is important to recognize that ICT-based solutions
should be an integral part of a country’s health policy
rather than being limited to the ICT
Ministry/Department. It is therefore recommended that
the necessary capacity-building in the health sector
be made at the policy, institutional and technical
levels. Bearing in mind the trends and good practices
described above, the following recommendations,
addressed primarily to health-care policymakers, have
been made with a view to integrating the ICT and
health-care sectors.
Promoting ICT to enrich the skills of health workers in
rural areas: Health workers in least developed
countries may lack the ICT skills required to benefit
from online medical resources, distance learning or
computer-based training. Least developed countries
often lack qualified technical staff capable of
supporting the national ICT infrastructure and
developing applications, as well as training users.
Recommendation: In order to expand the health-
care work force and enrich their skills, health
policymakers should invest in developing training
and reference materials for distance learning
through mobile phones and the Internet and
encourage health workers to use these resources.
In parallel, such initiatives may be supported by
advisory call centres established to reinforce the
skills of health workers.
Additionally, in order to develop sufficient human
capacity to maintain the telecommunications
infrastructure, ICT policymakers should seek to
strengthen ICT education among the population as
early as possible and promote the translation of
open source software into local languages.
Promoting ICT applications: It is challenging to
develop easy-to-use tools and applications which are
available in local languages and utilize the existing
infrastructure, such as the Internet and mobile
telephones, efficiently.
Recommendation: To make the drug and medical
supplies markets more transparent and efficient,
health policymakers should support the
establishment of tools such as government
procurement websites and private electronic
marketplaces. Policymakers in countries that have
no legal frameworks regulating electronic
commerce may consider adopting the United
Nations Commission on International Trade Law
model for electronic commerce laws.
4
In addition, health policymakers should invest in
easy-to-use and customized ICT applications and
promote online or CD-based training and
knowledge sharing tools in local languages so that
health-care stakeholders can share good practices
for building and operating health infrastructure (for
example, public health awareness materials, clinic
construction blueprints and management software).
Given the extraordinary growth of mobile phone
use in rural areas, incentives should be given to
encourage the development of local-language
health applications and awareness campaigns
through these devices.
Infrastructure and connectivity: The challenge most
least developed countries face is the limited amount
of financial resources available to invest in expanding
ICT connectivity to rural areas. Until the economic
crisis and its severe social impacts are overcome, it
will likely be difficult for policymakers to obtain
significant funding for investment in ICT for health
from national budgets. In addition, making a case for
investing in projects not directly related to health care
rather than new clinics, drugs or medical equipment is
a challenge.
Recommendations: In the constraining situation of
resource generation, it is important to make better
use of existing technologies, such as radio,
television, satellite television, mobile phones, and
satellite-based voice and data links.
Health policymakers should collaborate closely with
other government sectors to deliver education,
government services, business opportunities and
improved health-care through community centres
connected with ICT. In other words, the business
case for public spending in ICT connectivity should
not be seen in isolation, but rather holistically as
part of a broad strategy to improve the quality of life
and reduce poverty.
At present, most demographic and socio-economic
data are being shared across and within the
countries using National Spatial Data Infrastructure.
These data could be used for the development of
health-care systems and responses to public health
events, such as the spread of certain infectious
diseases and pollution events driven by socio-
economic and environmental conditions.
Finally, policymakers should explore policies that
reduce trade barriers on ICT equipment or give
consumers and businesses tax incentives to
purchase ICT equipment. An alternative means of
obtaining financial resources for investing in ICT
infrastructure is to implement universal service
obligation funds.
Policy and legal framework: The regulation of
commerce in drugs, medical equipment and services
is challenging. Often, patients receive poor treatment
from unlicensed medical practitioners and incorrect
information from poor quality sources; they may also
obtain low-quality counterfeit drugs in their local
markets. With the use of new technologies, some of
these problems will be exacerbated and the risk that
patient privacy may be violated will increase.
Recommendation: Health policymakers should
review the legal framework regulating the provision
of health services which use ICT to ensure that
they are neither impeded nor abused. Policymakers
should inform public and private health
stakeholders of the existing regulations and the
opportunities for provision of new types of health
services. Policymakers may wish to include
regulations to inhibit commerce in low quality drugs
by using methods such as enabling the verification
of a drug’s authenticity by telephone. Legal
frameworks should also ensure data protection and
safe electronic exchange of patients’ data.
Public-private partnerships to promote ICT for
health care: The growth of the ICT sector is primarily
driven by private industry, while the health-care sector
in developing countries is largely driven by
Governments. Developing infrastructure, ICT
applications, human capacity and finding financial
resources for delivering health services to rural areas
requires collaboration between public and private
sector stakeholders. Attracting these partners and
coordinating their activities is a challenge.
For further reading
ESCAP, 2007. e-Health in Asia and the Pacific,
Challenges and Opportunities.
InfoDEV, 2006. Improving Health, Connecting People:
The role of ICTs in the Health Sector of Developing
Countries.
UN Foundation-Vodafone Foundation Partnership,
2009. mHealth for Development: The Opportunity of
Mobile Technology for Healthcare in the Developing
World.
ESCAP, 2007. Health and the MDGs.
______________________________
1. http://www.unescap.org/stat/data/syb2008/4-Child-health.asp
2. The Millennium Development Goals: Progress in Asia and the
Pacific 2007. Executive summary,
www.unescap.org/stat/mdg/MDG-Progress-Report2007.pdf
3. The State of the World’s children 2009, (UNICEF, 2008).
Page 68. unicef.org/sowc09/docs/SOWC09-FullReport-EN.pdf
4. Health and the MDG’s. (ESCAP, 2007). Page 86.
5. A Comparison of Computer-Based and Standard Training in
the Integrated Management of Childhood Illness in Uganda May
2002, (USAID, 2002).
6. nhsdirect.nhs.uk/help/index.aspx
7. mHealth for Development, (United Nations Foundation,
Vodafone Foundation,2009). Page 14, 16.
8. Richard Wootton "telemedicine" The Oxford Companion to
Medicine. Stephen Lock, John M.
Last and George Dunea. Oxford University Press 2001.
9. economist.com/sciencetechnology/displayStory.cfm?
story_id=13688152 (The economist, 2009).

Recommendation: Least developed countries

should establish strong partnerships with private
sector entities, as well as other countries and
organizations to integrate ICT with the health-care
sector. As the mobile telephone market is growing
strongly in developing countries and
telecommunication companies are competing
vigorously for a share of it, policymakers may
encourage mobile operators to develop and deliver
public health services and applications through
their devices. Such services can be of interest to
operators as a way to attract new and loyal clients.
Such partnerships may include the delivery of
health reference materials and public awareness
campaigns. On the other hand, least developed
countries should join regional cooperation
mechanisms with other countries that are willing to
share their expertise and health research.

This Policy Brief on ICT Applications in the Knowledge Economy has been prepared by the Information and Communications
Technology and Disaster Risk Reduction Division of ESCAP to provide a brief introduction on selected ICT applications, identify
issues for implementation, and provide policy direction for the promotion of the applications. For further information on this Policy
Brief, please contact: Mr. Xuan Zengpei, Chief, Information and Communications Technology and Disaster Risk Reduction Division
(e-mail: xuan@un.org).